Employment Application LARSON CONTRACTING CENTRAL, LLC

LARSON CONTRACTING CENTRAL, LLC
508 W Main ST PO Box 7 Lake Mills, IA 50450

(641)592-5800 (507)373-6645 (800)765-1426
APPLICATION FOR EMPLOYMENT
Please fill out completely - RETURN COMPLETED FORM

Auxiliary aids and services are available upon request to individuals with disabilities.
Positions Applied For
Date of Application

MonthDayYear
Date
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Type a question

AdvertisementFriend/RelativeEmployment AgencyWalk-inOther
Name

First NameMiddle NameLast Name
Address Number
Street
City
State
Zip Code
Telephone Numbers
Social Security Number
PRE-EMPLOYMENT DRUG SCREENING IS REQUIRED
Best Time to Contact You? AM or PM
If you are under 18 years of age, can you provide required proof of eligibility to work?

YesNo
Type a question

YesNo
If YES when
Have your ever been employed with us before

YesNo
If YES when
Are you currently employed?

YesNo
May we contact your employer?

YesNo
Are you a military veteran?

YesNo
if Yes, dates of active duty:
Are you prevented from becoming employed because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment

YesNo
On what date would you be available to work:
Are you available for work:

Full TimePart TimeTemporary
Are you currently on "Lay-Off" status or subject to recall?

YesNo
Can you travel if the position requires?

YesNo
Have you ever been convicted of a felony within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.

YesNo
If YES, please explain:
[WE ARE AN EQUAL OPPORTUNITY EMPLOYER]
The law prohibits discrimination in hiring due to age, race, color, creed, sex, national origin, religion, YES NOdisability/veteran status or any other protected status.

On what date would you be available to work: Are you available for work:

Are you currently on "lay-off" status or subject to recall?
EMPLOYMENT EXPERIENCE:
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the 7 years prior to the initial 3 years (total of 10 years employment record
Employer
Dates Employed
Address
FROM
TO
City
ST
Zip
HOURLY RATE/SALARY
Job Title
Supervisor
START
FINAL
WORK PERFORMED
Reason for Leaving
EXPLAIN GAPS IN EMPLOYMENT
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
Employer
DATES EMPLOYED
Address
FROM
TO
City
ST
Zip
HOURLY RATE/SALARY
Job Title
Supervisor
START
FINAL
WORK PERFORMED
Reason for Leaving
EXPLAIN GAPS IN EMPLOYMENT
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
Employer
DATES EMPLOYED
FROM
TO
Address
City
ST
Zip
HOURLY RATE/SALARY
Job Title
Supervisor
Starting Pay
Final Pay
WORK PERFORMED
Reason for Leaving
EXPLAIN GAPS IN EMPLOYMENT
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
License Information
State
License No
Type
Expiration date

MonthDayYear
Date
PREVIOUS 3 YEARS RESIDENCY
Address Number
Street
City
State Zip Code
# of Years
Driving Experience

Type of equipment - (Van, Tank, Flat, Etc)
Please list type of equipment you have experience with. Dates of experience, and the approximate number of miles driven. Please list in detail and experience with this TYPE OF EQUIPMENT - (VAN, TANK, FLAT, ETC)
Accident Record for the past 3 years or more please list Date(s) of accident, nature of accident (head-on, rear-end, upset, etc), the number of fatalities (if any), the number of injuries (if any), and were there any Chemical Spills involved.
Traffic Convictions & Forfeitures for the past 3 years (other than parking violations) Please list: Date Convicted, Violation, State of Violation and Penalty for each
Have you been denied a license, permit, or privilege to operate a motor vehicle?

YesNo
If YES please explain
Has any license, permit or privilege ever been suspended or revoked? If YES, please explain:

YesNo
If YES please explain
Education
Name of High School
Course of Study
Years of Study
Graduation Date
Diploma / Degree
Undergraduate
Name of School
Course of Study
Years of Study
Graduation Date
Diploma / Degree
Graduate
Name of School
Course of Study
Years of Study
Graduation Date
Diploma / Degree
Other School or Special Experience
Name of School
Course of Study
Years of Study
Graduation Date
Diploma / Degree
QUALIFICATIONS & SKILLS
Describe any special training experience apprenticeship skills activities languages memberships andor civic activities You may exclude anything that would reveal gender race religion origin age disability or other protected status
SPECIALIZED SKILLS
Check All that Apply

BobcatAir GunsWeldingCarpentryConcreteFork LiftDump TruckMechanicalRoofingMasonryBackhoeLoaderSite WorkSteel ErectionComputer
OTHER
NOTE TO APPLICANTS
Do not answer this question unless you have been informed about the requirements of the position for which you are applying

Are you capable of performing the activities involved in the job or occupation for which you have applied?
Type a question

YesNo
REFERENCES
Name
Address
Phone
Relationship
Name
Address
Phone
Relationship
Name
Address
Phone
Relationship
APPLICANT STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. I authorize you to make sure investigations & inquiries to my personal, employment, financial, or medical history & other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if & after a conditional offer of employment has been extended I hereby release employers, schools, health care providers & other persons from all liability in responding to inquiries & releasing information in connection with my application. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct, unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) & (e I understand I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers & for those previous employers to re-send the corrected information; Have a rebuttal statement to the alleged erroneous information, if the previous employer(s) & I cannot agree on the accuracy of the information.
SIGNATURE

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DATE

MonthDayYear
Date
LARSON CONTRACTING CENTRAL, LLC
508 W Main ST PO Box 7 . Lake Mills, IA 50450 (641)592-5800 . (800)765-1426

PRE-EMPLOYMENT SELF-IDENTIFICATION FORM

Anti-Discrimination Notice: It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual's terms and conditions of employment, because of such individual's race, color, religion, sex, or national origin.

This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes. If you choose not to self-identify your race/ethnicity at this time, the federal government requires this employer to determine this information by visual survey and/or other available information. For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven categories identified below.The definitions for each category have been established by the federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below.
PRE-EMPLOYMENT SELF-IDENTIFICATION FORM
LAST
FIRST
MI
Date

MonthDayYear
Date
Gender

MaleFemale
Position applied for
What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify

Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Black or African American: a person having origins in any of the black racial groups of Africa.Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity categories.
SIGNATURE

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Should be Empty:

LARSON CONTRACTING CENTRAL, LLC

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT DRUG SCREENING IS REQUIRED

[WE ARE AN EQUAL OPPORTUNITY EMPLOYER]

EMPLOYMENT EXPERIENCE:

HOURLY RATE/SALARY

DATES EMPLOYED

HOURLY RATE/SALARY

DATES EMPLOYED

HOURLY RATE/SALARY

License Information

Driving Experience

Education

Undergraduate

Graduate

Other School or Special Experience

QUALIFICATIONS & SKILLS

SPECIALIZED SKILLS

NOTE TO APPLICANTS

REFERENCES

APPLICANT STATEMENT

LARSON CONTRACTING CENTRAL, LLC

PRE-EMPLOYMENT SELF-IDENTIFICATION FORM